The night is no longer young. Your friend, life of the party a few hours ago, is passed out on the couch. But how drunk are they? Do they just need a helping shoulder to stagger off to bed, or is this the level of drunk that warrants a call to the hospital?

Back-to-school is prime time for alcohol-related hospital visits, mainly because people who aren’t used to heavy drinking take it up as a hobby when they get to college. But too many dangerously drunk people don’t make it to the ER when they should: either their friends don’t know the warning signs that somebody needs medical attention, or they’re afraid of getting in trouble by involving authorities.

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Before we get any farther, here’s the most important thing to know: If you’re not sure, call 911 anyway.

For a more complete answer, we talked to Dr. Ryan Stanton, a practicing emergency physician and spokesperson for the American College of Emergency Physicians. When people die from drinking too much, he says, it’s often because alcohol has impaired their ability to protect their airway.

Why Too Much Alcohol Is Dangerous

Alcohol is a central nervous system depressant, meaning it slows or impairs some of your brain functions. After a few beers, you’ll notice that it’s harder to walk straight or avoid texting your ex. After a few more, your vision and speech might be affected. Drink enough, and you won’t be able to regulate your breathing or activate life-saving reflexes.

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Unconsciousness is toward the deeper end of that continuum, which is why you may have heard the advice to keep a drunk friend awake. Since alcohol makes us sleepy, it’s not uncommon to find someone face-down in the middle of the party—not a problem if they’ve just dozed off because, you know, it’s late and they just pulled an all-nighter and that carpet looked so soft and comfy. We might refer to anyone we have to step over as “passed out,” but if someone is truly unconscious, they’re in trouble. How do you tell the difference between a sleepy person and an unconscious one? Try to wake them up.

That’s not the only thing to watch for, though. Here’s how Dr. Stanton put it:

The line [between someone who’s safe and someone who needs help] is not very well defined, especially when it comes to protecting the airway. You can have somebody who’s “passed out” from drinking who can protect their airway just fine. And then also you can have somebody who, just moments ago, was walking around and who is now sitting there apneic from aspirating on their own vomit. So it’s very difficult and basically what we tell everybody is if you have any concerns that the person’s not safe, bring them in.

Here’s the typical picture of someone who can’t protect their airway, he says: you can’t wake them up, and they’re vomiting but aren’t trying to get the vomit out of their mouth or roll over to try to clear it. In extreme cases, alcohol can cause a person’s breathing to slow to dangerous levels or result in their slipping into a coma—so don’t assume an unconscious or unresponsive person is okay just because they’re not vomiting.

The other big danger to a drunk person is trauma, especially head injuries. Someone can fall because alcohol makes them clumsy, then get up again because alcohol dulls their response to pain. If you see blood, bruising, or swelling, especially on someone’s head, that could signify a serious injury.

Trauma can also come from bad decisions like deciding that now is a great time to get into a fight or jump off a balcony or goof around on a boat (70% of water recreation deaths involve alcohol). Or, you know, get behind the wheel of a car. Even the mildly tipsy can cause serious accidents; don’t risk it.

What You Should Do with a Too-Drunk Friend

If you’re on a college campus, you probably got a handbook or a brochure at some point telling you what to do in an emergency; take a look at that now, before you need it, and take note of the number if it’s anything other than 911. (Some schools have a “rescue squad” that can get to you faster than local police.)

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If the person is conscious and responsive—in other words, not “call 911” drunk, you should:

Stay with them. Or if you’re drunk too, find a sober friend to take over. Even if they’ve stopped drinking, they may not have absorbed all the alcohol in their digestive tract, so it’s possible they could get worse before they get better. Check on them often to make sure they stay responsive, and be ready to call for help if needed.

Get them to a safe place, like home or a friend’s place. Don’t rape them. And don’t drive them anywhere if you’re drunk too.

Put them into a recovery position like this one (shown below). The idea is to position them so that vomit will fall out of their mouth if they take a turn for the worse. Remember, if you think they’re likely to choke, you should skip to the next section about calling for help.

Don’t try to sober them up with coffee or cold showers or whatever helpful suggestions people are offering. Their liver just needs time to do its job.

If the person is not responsive or if they’re showing any scary symptoms (like unconsciousness, slow breathing, or seizures—anything that worries you),

Call for help (911 or the rescue squad).

Stay with them until help arrives. Put them into a recovery position, and if you can, find somebody who knows how to do CPR—just in case.

Tell emergency responders what happened—how many drinks they had, what kind, and their symptoms or injuries.

Even if you’re afraid of getting in trouble, it’s still better to call. Many states, and many colleges, have laws or amnesty policies that protect you from criminal charges or serious disciplinary action if you’re doing the right thing. Regardless, emergency personnel are more interested in saving lives than turning people in. Here’s Dr. Stanton, who practices in Kentucky:

If you take somebody to the ER, we don’t see the police coming after them and writing tickets or sending people to jail. Now if somebody’s doing something illegal at the party, like an adult having a bunch of minors, yes. But if you get somebody to the ER and get them help, we rarely see them with legal problems. Because many times I think the police feel like having to go to the ER, having to go through that and cost associated with it is probably punishment enough, and probably not as much punishment as when we call your parents and have them show up from 3 or 4 hours away towards the morning and they’re sitting by your bed when you wake up. So the more important thing is to think about somebody from a health and safety standpoint and not worry about the ramifications on the back end.

So, yes, there will likely be a parental phone call. Sorry.

What Happens at the Hospital

By the time somebody gets to the hospital, there’s no point in pumping their stomach; they’ve generally barfed everything up by then. Instead, Dr. Stanton says, hospital staff does three things:

Monitor the person—the high-tech version of what you were doing when you were checking on them constantly. They’ll make sure your friend is breathing normally, keeping a safe body temperature, and so on.

Support their vitals, for example giving fluids as needed and medications to control pain or nausea.

Once the person sobers up, they’ll get a more thorough exam to check for any injuries or other issues that may have come up. If nothing is seriously wrong, they’ll usually get to go home in the morning.

Illustration by Tara Jacoby. Recovery position illustration by PimboliDD.